Provider Demographics
NPI:1205104593
Name:PULLMAN REGIONAL HOSPITAL CLINIC NETWORK LLC
Entity type:Organization
Organization Name:PULLMAN REGIONAL HOSPITAL CLINIC NETWORK LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GROVER 'PETE'
Authorized Official - Middle Name:C
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:509-332-6139
Mailing Address - Street 1:840 SE BISHOP BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-5502
Mailing Address - Country:US
Mailing Address - Phone:509-332-6139
Mailing Address - Fax:509-332-6579
Practice Address - Street 1:1420 S BLAINE ST STE 5
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-3973
Practice Address - Country:US
Practice Address - Phone:208-882-2247
Practice Address - Fax:509-336-7482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-01
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208000000X, 2084P0800X
ID13-3860261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID13-3860OtherCMS CERTIFICATION
ID1369068OtherMEDICARE PTAN